When Sleep Is Not Enough

Like depression, insomnia used to be treated as a symptom of “something else.” Not anymore. At this year’s national sleep meetings in Denver, it became clearer how big a national and international problem insomnia is – as well as how to fix it.

As insomnia researcher Charles Morin pointed out, the distinction between “primary” and “secondary” insomnia is gone. Insomnia afflicts people – and many of the people around them – through effects that affect much of modern life.

If you don’t feel you get enough sleep, there can be hell to pay. Here are a few examples:

Economic – people with insomnia are unhappy, irritable, more prone to accidents and errors of judgment, and less productive. They are also less helpful to their colleagues. Though the problem is worst at the bottom of the economic scale, with people trying to commute and work to three part-time jobs choosing between time asleep or time for work and family, CEOs are also hit. The reason? International travel and 24/7 schedules. Humans are not machines. We just try to act like we are. One of the biggest “trends” for CEOs are executive trainers who specialize in “getting people sleep” and overcoming jet lag. It’s not just shift workers now. Biological clocks have arrived in the executive suite.

Medical – People who get sick – whether it’s colds or cancers – sleep less effectively, and take longer to regenerate themselves. A big trend in insomnia research is the realization of how much insomnia affects cardiovascular disease, through more hypertension and heart attacks. As is often the case with insomnia, there is an endlessly increasing dialectic – more medical problems make for more insomnia, and more insomnia makes for more medical problems.

Psychiatric – Ever since Boris Angst in Zurich showed how a third of insomniacs eventually become depressed, people have been paying attention. According to Morin, insomnia doubles the rate of depression, a finding consistent throughout the world. Tom Wehr in the US showed two decades ago he could manipulate mania or depression by changing people’s sleep times. If you want to see schizophrenia burst out in its full, naked form, observe people who consistently can’t sleep.

Military – sleep in armies and navies gets too little attention. Soldiers in combat zones often sleep poorly. Ongoing research by the US military demonstrates how this sets up soldiers to make potentially catastrophic errors, both military and moral. Plagued by traumatic brain injury and post-traumatic stress disorder, the American military now recognizes it has huge sleep problems. Insomnia is the thread that runs through most of them.

Sleep deprive an animal long enough and it dies. Those experiments have not been done in people – very thankfully. But mess up rest and all kinds of bad things happen, to ourselves and our communities. Fortunately, the right treatments work.

Treatment

Worldwide, the most common treatment for insomnia is pills. The most effective treatment is cognitive-behavioral techniques for insomnia, or CBTi. This mismatch leads to much mayhem.

Looking at the data of Dan Kripke, an emeritus professor at the University of California, San Diego, regular sleeping pill use is associated with a mortality odds ratio of five – five times the death among people using sleeping pills as compared with controls. Other studies have found somewhat lesser fatality numbers, but they remain scary. People regularly using sleeping pills have higher death rates in cardiovascular disease; accidents; even cancer.

The CBTi approach generally starts with behavioral techniques. That means teaching people about biological clocks and how to sleep, something many in the internet age have forgotten. Machines can go full blast all day. We can’t. We need rest like we need food. Teaching people the basic principles of sleep is now gaining more attention, one of the reasons I started sleepuniversity.org.

Following behavioral techniques, people learn cognitive ones – how their thinking about sleep changes their sleep. Combining behavioral with cognitive techniques, people learn how to approach sleep in terms of solutions, not just problems. They recognize that staying in bed when you can’t sleep doesn’t help. They learn that not every night of sleep is not perfect. They begin to see how body clocks influence so much of their lives. They figure out ways to think differently, not just about sleep, but about health in general.

CBTi is now used all over the world in hundreds of different configurations. Many companies are putting it out on the web. Manuals short and long exist by the truckload. It’s not just effective, it’s cheap.

The profit margin on sleeping pills is much, much greater.

The Future

Insomnia researchers, like depression researchers before them, are trying to subtype different kinds of insomnia. They’re trying to figure out how it occurs, including the realization that in insomnia not all of the brain is “asleep” when people think they’re sleeping.

Yet the basic teaching is simple. We need sleep to live. To sleep well we have to treat our bodies as bodies, not machines. And for the 10% of the population that already has bad insomnia, the most safe and effective treatments don’t involve drugs.